Review Tracking Tool

About INTERACT

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition. The INTERACT program includes clinical and educational tools and strategies for use in every day practice in long-term care facilities. The goal of the INTERACT program is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. We provide this access with no warranty or guarantee that use of these materials will reduce rehospitalization rates. For more information, go to the INTERACT website.

This flow chart of the INTERACT Program guides users through the process and tools to be used in the INTERACT program. Download for free from the INTERACT website.

Note: This tool is also found in the INTERACT Implementation Guide 4.0 (item # MP5651-4).

Overcome barriers to INTERACT implementation into everyday care with visuals and explanations of the process, strategies and tools.

This 15 page guide provides an overview of the INTERACT Program and an explanation of the purpose of each tool plus strategies for overcoming barriers to INTERACT implementation and sustaining care process improvement.

This tool for use by facility leadership and outside organizations, like hospitals, health systems, ACOs, etc., is used to summarize INTERACT implementation and outcomes. Download for free from the INTERACT website.

This Policy and Procedure Manual provides organizations with a Best Practice Model approach resource on implementation of the INTERACT Quality Improvement Program.

This thorough training course provides a detailed description of the Quality Improvement Program, care processes, tools, and other resources to improve care of changes in condition and prevent unnecessary hospitalizations.

Review, document and summarize resident transfers to identify opportunities to improve identification, evaluation and management of resident change in condition.

This tool is a paper and pencil worksheet that can be used to calculate hospital transfer measures to enter into an Excel or other data base. Download for free from the INTERACT website.

Hospitalization Rate Tracking Tool (Free Download)

This tool for use by facility leadership and members of the quality committee can be used to calculate hospital transfer outcomes (unplanned admissions, 30-day admissions, emergency room visits without admission) using standard definitions, and identify trends. Download for free from the INTERACT website.

This QI form reviews and documents transfers to identify opportunities to improve identification, evaluation and management of resident change in condition and other situations that commonly result in transfers to the hospital; and when feasible and safe, to help prevent transfers.

This worksheet is used to summarize findings from the Quality Improvement Tool (item # MP5642-4) to determine if there are common factors involved in your hospital transfers that can help improve care and reduce potentially preventable hospital transfers.

Use these tools to prompt staff - including CNAs, dietary, rehab and environmental services - to communicate changes in condition with nursing staff. Nursing staff can use the information to enhance nursing evaluations and communication with primary care clinicians.

The “Stop and Watch” Early Warning Tool prompts staff, including CNAs, dietary, rehab and environmental services, to be alert for potential change in condition indicators. This tool provides a simple, clear way to communicate changes in condition to nursing staff.

Available in a convenient 2-part, booked format, this “Stop and Watch” Early Warning Tool prompts staff, including CNAs, dietary, rehab and environmental services, to be alert for potential change in condition indicators. This tool provides a simple, clear way to document and communicate changes in condition to nursing staff.

This convenient 2-part, Spanish, pocket-sized 'booked' version makes it easy to carry and document possible observed changes in a resident's condition.

The SBAR is designed to enhance the nursing evaluation of and documentation for residents who have an acute change in condition. This tool is intended to help structure and improve communication with primary care clinicians.

For patients discharged from acute hospitals for post-acute care, medication reconciliation is a critical task. This worksheet is designed to help nurses, primary care providers and pharmacists develop accurate and safe medication orders at the time of admission for new admissions from the hospital or residents returning from the hospital.

Utilize these communication tools to help clearly and succinctly communicate a wide range of critical information to the hospital, as well as provide resident's medical documents and belongings to emergency room staff during acute care transfers.

These tip sheets provide keys to improving communication and collaboration with hospitals, a hospital engagement checklist, as well as, an explanation on how INTERACT can help hospitals better manage readmissions and why collaboration with nursing homes is important. Download for free from the INTERACT website.

This tool for use by all nursing home licensed nursing staff and ER staff provides a standardized pre-populated checklist explaining nursing home capabilities for decisions about transfers back to the nursing home. It is recommended that it be posted in emergency rooms and provided to hospital discharge planners. Download for free from the INTERACT website.

This form helps the nursing home clearly and succinctly communicate a wide range of critical information about the resident to emergency room and other hospital staff to help facilitate a transfer that is more effective and less disruptive to the nursing facility resident so there is no lapse in the resident’s care.

This tool for use by all nursing home licensed nursing staff and ER staff provides recommended data elements to be included in paper or electronic forms. Download for free from the INTERACT website.

The Transfer Checklist Envelope is designed to ensure that personal belongings and contents, such as medical documents, necessary for emergency room staff to make appropriate evaluation of the resident, accompany the resident to the hospital.

This tool for use by all nursing home licensed nursing staff and primary care clinicians; and hospital discharge planners, nurses and discharging physicians provides recommended data elements to be included in paper or electronic forms at the time of transfer from the hospital to the nursing home or SNF. Download for free from the INTERACT website.

Use Decision Support Tools in everyday care to help the recognition, evaluation, management and reporting of specific symptoms and signs.

This stand-up guide provides decision support tools to help nursing staff determine whether to report specific symptoms, signs and lab results immediately versus non-immediately (e.g. the next day) to primary care clinician (MD, NP and/or PA).

The pocket-sized guide provides decision support tools for the nursing staff to help with determining whether to report specific symptoms, signs and lab results immediately or non-immediately (e.g., the next day). This pocket guide also contains all ten of the Care Paths including, dehydration, fever, and more.

This 14-page, coil-bound book contains the ten Care Paths, educational decision support tools that provide guidance on the recognition, evaluation, and management of the conditions that commonly cause hospital transfers, and provide guidance on when to notify the primary care clinician.

The Care Paths Kit consists of ten posters, one for each Care Path, and one coil-bound Care Paths Guide that also contains the ten Care Paths. The Care Paths are educational decision support tools that provide guidance on the recognition, evaluation, and management of the conditions that commonly cause hospital transfers, and offer guidance on when to notify the primary care clinician.

Use these INTERACT tools to document plans and discussions after a New Resident Admission, at regular intervals (Resident Re-Assessment) or if MD/NP/PA has been notified of a decline in condition.

This educational tool is designed to assist health professionals who work in nursing homes on how to communicate with residents and their families about goals of care and preferences at the time of admission, at regular intervals, and when there has been a decline in health status.

This form provides a way to document and track when advance care planning discussions occurred and details of the information discussed.

This educational tool lists criteria to help nursing home staff determine residents who may be appropriate for hospice care, palliative care or comfort care orders. Download for free from the INTERACT website.

Note: This tool is also found in the Advanced Care Planning Communication Guide (item # MP5654-4).

This tool for licensed nurses and primary care clinicians provides guidance in the form of examples of orders that may be appropriate for residents on palliative or comfort care plans who decline hospice. Download for free from the INTERACT website.

Note: This tool is also found in the Advanced Care Planning Communication Guide (item # MP5654-4).

This educational tool is designed to help health care professionals, residents and their families review the risks and benefits of hospital care versus staying in the nursing home to help make the right decision about hospitalization.

This educational tool, provided to the resident and families, uses illustrated vignettes to explain CPR, the risks and benefits and addresses choosing CPR or DNR in addition to listing supplemental information sources.

This educational tool, provided to the resident and families, uses illustrated vignettes to explain tube feeding, the risks and benefits and addresses choosing tube feeding or not in addition to listing supplemental information sources.